73. Dysuria Flashcards
Index conditions (3)
- Urinary tract infection
- Urethritis (including sexually transmitted disease)
- Prostatitis
Aetiology.
a) Abdominal
b) Urinary tract causes: infective
c) Urinary tract causes: non-infective
d) Drug irritants
e) Chemical irritants
f) Mechanical irritants
a) Acute emergencies (eg. appendicitis and ectopic pregnancy) due to irritation of nearby urinary structures
b) - UTI - cystitis, interstitial cystitis, pyelonephritis
- Urethritis (e.g. chlamydia, gonococcus or non-gonococcal urethritis, reactive arthritis)
- Schistosomiasis
- Women: vaginitis - thrush, atrophic vaginitis, BV
- Men: prostatitis, epididymo-orchitis, epididymitis.
c) - Obstruction: prostatic enlargement, urethral stricture, kidney stones in the bladder or urethra; pelvic mass
- Malignancy - eg, carcinoma of the bladder, prostate or urethral tumours
- Genital causes: Urethral or vaginal trauma, including sexual abuse or a foreign body
d) Drug irritants:
- Cyclophosphamide, allopurinol, danazol, NSAIDs
e) Chemical irritants:
- allergic or irritant reaction to soaps, lubricants, spermicides, tampons
- Radiation or chemical exposure
g) Mechanical irritation:
- poorly fitting contraceptive diaphragm / pessary.
Dysuria: associated symptoms
a) Radiation of pain to loin/back
b) Fever, rigors or malaise, unwell (obs)
c) Haematuria
d) Urethral or vaginal discharge
e) Pruritis
f) Frequency and urgency
g) Voiding symptoms (eg. poor flow, dribbling)
a) Suggesting upper urinary tract pathology.
b) suggest pyelonephritis.
c) Infection, stones, neoplasms and renal disease (e.g. GN).
d) consider STI
e) Thrush/ STI
f) indicate bladder irritation (e.g. cystitis)
g) consider obstruction (eg. BPH)
Dysuria: investigations
a) Bedside
b) Bloods
c) X-rays/imaging
d) Special tests
a) Obs (?septic), urine dip (+MCS), pregnancy, STI swabs, ?bladder scan, ?PR
b) FBC, CRP, urea and creatinine, ?PSA, ?cultures
c) XR/CT KUB (stones), USS (obstruction, masses, hydronephrosis, etc.)
d) Urodynamics, cystoscopy
UTI: causes
a) General
b) Hospital acquired/associated with abnormalities
c) Catheter/instrument-associated
a) e. coli, staph saprophyticus, proteus, klebsiella
b) Pseudomonas
c) staph epidermidis, enterococcus faecalis
UTI: who should be investigated?
a) Patient demographic
b) Clinical features
a) men; pregnant women; children < 3 years;
b) - suspected upper UTI;
- complicated infection, or recurrent infection;
- if resistant organisms are suspected;
- if clinical symptoms are not consistent with results of dipstick testing
Uncomplicated lower UTI: management
a) Main one (CI?)
b) Alternatives (CI?)
c) Advice for patients
a) Oral trimethoprim (200mg BD for 3 days, or 7 days), not in first trimester - folate antagonist = NTDs
b) Oral - nitrofurantoin (check renal function; avoid in 3rd trimester), amoxicillin, ampicillin or cefalexin.
c) Drink plenty of fluids; paracetamol for pain; safety net for signs of sepsis, non-improvement or recurrence
UTI in pregnancy.
a) Mainstay of treatment (2 options)
b) Advice on trimethoprim
c) Advice on nitrofurantoin
d) Other antibiotics to avoid during pregnancy (with foetal side effects)
a) Amoxicillin, cephalosporin (oral = cefalexin)
b) Avoid in first trimester (caution eleswhere)
c) Avoid near term (final 30 days) - may result in neonatal haemolysis
d) - Tetracyclines: cause discoloration of the teeth and enamel hypoplasia
- Chloramphenicol: grey-baby syndrome
- Aminglycosides: risk of sensorineural hearing loss (avoid unless essential)
UTI in children: acute management
a) Presentation in infants
b) Presentation in toddlers/children
c) Management of suspected lower UTI in < 3 months
d) Management of suspected lower UTI in > 3 months
e) Management of suspected pyelonephritis
a) Fever, vomiting, lethargy, irritability, poor feeding, FTT
b) As for adults; plus: vomiting, poor feeding, dysfunctional voiding, or changes to continence
c) - Refer urgently to paediatrics
- Treatment with IV antibiotics
- Send urine sample sent for urgent MC+S
d) Urine dip:
- Leuk+/nitrite+or just nitrite + = start ABx
- Leuk+ = send for MC+S
- Leuk-/nitrite- = do not send urine, do not treat
e) - Admit to hospital
- oral cefalexin or co-amoxiclav
Catheter-associated UTI.
a) Presentation
b) Bacteriuria
c) Management
a) As for normal UTI, plus: change in urine colour/smell
b) - Not an indication for ABx in patients with indwelling catheters
- After 1 month, nearly all catheterised patients will have bacteriuria
c) - Admit if septic
- Check catheter is functioning / not blocked, etc.
- Remove (or change) catheter if indwelling for > 7 days
- Take urine sample for culture (MSU if catheter removed; from new catheter if catheter changed)
- ABx - empirical (nitro, trim, amox, cef, etc.) - 7 days
Pyelonephritis.
a) Risk factors
b) Presentation
c) Investigations and management
a) - Structural (obstruction/reflux) - VUR, renal calculi, prostate enlargement, neuropathic bladder
- Infection risk - catheterisation, stents or drainage procedures, pregnancy, diabetes, immunocompromised
b) Fever, rigors, loin pain and tenderness; septic
c) - If septic/systemically unwell/at-risk - admit and A-E with Sepsis 6 and IV fluids and antibiotics
- Bedside: urine dip (+ MSU), pregnancy test
- Bloods: FBC, CRP, U+Es/creatinine, ?cultures
- Imaging: ?USS (+ CT KUB if calculi suspected)
- ABx: co-amoxiclav or ciprofloxacin (beware c. diff)
- Surgery: may be required to relieve obstruction or drain abscesses
Staghorn calculi.
a) Composition
b) Organism predisposing to formation - generally have urine pH more than…?
a) Struvite (magnesium ammonium phosphate)
b) Proteus
- urine pH > 7
